2.0 Analysis 2.1 Introduction The investigation identified that certain operating practices established by management were not being effectively transmitted to the operating personnel, and that the regulatory agency (Transport Canada) did not effectively monitor the company operations when the company was operating at bases remote from the supervising regional office. Operating irregularities that allowed this aircraft accident to occur include the crew's use of an aircraft configuration that did not allow for adequate margins for landing performance (stopping distance) and the captain's inadequate handling of the aircraft during the approach. 2.2 Company Management The operating practices of the company, as directed at the management level of Director of Flight Operations and Chief Pilot, were not effectively transmitted to the flight crews. Policies distributed by the company in the form of Standard Operating Procedures and other manuals were not put into effect at the operating level at the Vancouver base. Specifically, the pilots did not use the runway analysis charts for calculation of landing distance. The result was repeated company operations into airports where the runway length available for landing was marginally acceptable or insufficient according to the required runway length indicated by the charts. 2.3 Transport Canada Monitoring Because Transport Canada did not monitor the operations of Canair Cargo at their Vancouver base with the same frequency that they would have in the Ontario region, they were not able to ensure that all company operations were being performed to the required standard. 2.4 Aircraft Configuration/Use of Runway Analysis Charts The landing performance charts for Tofino indicated that a safe landing could only be conducted with a flap 40 setting, yet there was no discussion in the cockpit when the captain briefed that the landing configuration was to be 28-degree flap. Company SOPs did not include landing performance data as an item to be briefed prior to landing. Thus, the flight crew used an aircraft configuration that may not have allowed for adequate margins for landing performance (stopping distance). 2.5 Approach Effectiveness The weather at the time of the approach was suitable for a visual approach to the airport, after the aircraft had completed the procedure turn and was established inbound to the airport. The crew conducted a visual approach, but the captain did not maintain the required descent profile to ensure a safe touchdown near the runway threshold and stop the aircraft in the distance available. The published approach procedure calls for a descent to minimum descent altitude and then a circling procedure for landing; however, the captain elected to fly a visual straight-in procedure to runway 28. The crew's lack of appreciation of the situation was exacerbated by the absence of the final approach descent planning information. If the required descent rates had been briefed prior to the approach, there might have been more indication to the crew that the approach was not proceeding normally. The combination of excessive altitude to be lost on final approach, a higher than target airspeed on final approach, and a tail wind component led to the aircraft not being in the required position to execute the straight-in landing on runway 28. Both crew members were qualified and experienced on the aircraft type. The captain had not, however, flown on this operation or into this airport prior to the day of the occurrence. The first officer had fewer flying hours on type and in total, but was familiar with the Tofino Airport. 2.6 Pilot Decision Making Throughout the approach, the captain received, and acknowledged, information from the first officer which indicated that the aircraft was above the optimum descent profile and desired speed. Further, comments about the significant tail wind encountered on the approach were made by both crew members. Notwithstanding these cues, and the perspective provided from the cockpit, the captain continued with the approach. The first officer could have been more assertive in expressing her discomfort with the approach profile. However, neither crew member had CRM training; the lack of assertiveness and the lack of corrective action by the captain were responses which could have been expected from a crew without such training. The incorrect descent profile, higher than normal approach speed, and tail wind should have dictated a missed approach; the captain, however, elected to continue with a landing, which resulted in a long touchdown and insufficient runway remaining on which to stop the aircraft. The following laboratory reports were completed: LP 086/93 - Flight Data Recorder Report; and LP 087/93 - Cockpit Voice Recorder Repor. 3.0 Conclusions 3.1 Findings The aircraft's weight and centre of gravity position were within limits. The aircraft was certified in accordance with existing regulations and approved procedures. There was no evidence found of any airframe failure or system malfunction prior to or during the flight. A five-parameter foil-type FDR was installed on the aircraft. The company had been granted a waiver to permit the installation. The captain's aircraft handling during the approach procedure resulted in the aircraft not being in a position to carry out a safe landing. The captain elected to continue the landing attempt after an unsatisfactory approach, and the aircraft touched down about midway along the runway at a speed of approximately 111 knots indicated airspeed (KIAS). The aircraft touched down at a point on the runway which left insufficient distance remaining in which to stop. This was the second time that the captain had flown in to Tofino Airport, and the first time he had been there while performing the pilot flying duties. The captain had not received specific company training on landing performance requirements at the Tofino Airport, although he had been briefed. The flight crew used an aircraft configuration that may not have allowed for adequate margins for landing performance (stopping distance). The captain's approach briefing did not conform to the requirements specified in the company SOPs. The operating practices of the company at the management level were not effectively translated to the operating personnel. The regulatory agency (Transport Canada) did not effectively monitor the company operations when the company was operating at bases remote from the supervising regional office. The company did not provide a separate course of instruction in cockpit/crew resource management or pilot decision making, nor was such training required by regulations. 3.2 Causes The descent profile flown during the approach procedure resulted in the aircraft not being in a position to land safely; the captain elected to continue rather than conduct a missed approach, and the aircraft touched down with insufficient runway remaining in which to stop. Contributing to the occurrence were inadequate monitoring, by both the air carrier and Transport Canada, of aircraft operations remote from the company's main base. 4.0 Safety Action 4.1 Action Taken 4.1.1 Regulatory Audits and Surveillance Analysis and information from this investigation and 18 others led to the identification of shortcomings in the regulatory audit process of air carriers. In particular, it was found that Transport Canada's (TC) audits lacked depth, and that the verification of corrective action following the audits was inadequate. Therefore, the Board recommended that: The Department of Transport amend the Manual of Regulatory Audits to provide for more in-depth audits of those air carriers demonstrating an adverse trend in its risk management indicators; The Department of Transport ensure that its inspectors involved in the audit process are able to apply risk management methods in identifying carriers warranting increased audit attention; The Department of Transport develop, as a priority, a system to track audit follow-up actions; and The Department of Transport implement both short and long term actions to place greater emphasis on verification of required audit follow-up action and on enforcement action in cases of non-compliance. 4.1.2 Flight Recorder Legislation Over the years, the Board has made several recommendations concerning deficiencies in the retrieval and quality of flight recorded data and in the lengthy process required to update flight recorder legislation. Notwithstanding the emphasis that the Board has put on the importance of flight recorders for investigation and accident prevention purposes, there has not been significant progress in addressing these flight recorder deficiencies. Therefore, the Board recommended,inter alia, that: The Departments of Justice and Transport promulgate the new Orders on flight recorders without further delay; and The Department of Transport streamline its processes to facilitate the timely Canadian implementation of updated flight recorder requirements. In response, TC has indicated that it intends to issue two interim circulars to facilitate industry adjustment to the new flight recorder regulation expected to come into law in early 1995. Also, TC stated that new regulations will refer to associated standards, which should facilitate amendment action in a timely way. The Department of Justice has advised that it is prepared to carry out its regulatory functions as quickly as possible to ensure that the regulations proposed by TC can be promulgated with the least possible delay. 4.2 Action Required 4.2.1 Crew Resource Management and Decision Making Several factors led to the accident aircraft not being in the required position on final approach from which a safe landing could be executed. However, the accident could have been prevented if a decision had been made to discontinue the landing. The Board has investigated several recent occurrences3 where inappropriate decisions have been made by aircrew, although cues were available which should have alerted them to potentially dangerous situations. While this occurrence at Tofino hinged upon a pilot decision at a critical point in the approach and landing phase, inappropriate decisions occur in almost all aspects of flight operations. (See Appendix D for some examples of aviation occurrences with probable decision-making implications.) 3 TSB occurrences A90P0337, A91A0198, A91C0083, A92P0015, A93H0023, A94H0001, A94W0026, and A94A0078 The Board recognizes that there are pressures in commercial aviation to get the job done and that these pressures undoubtedly affect decision making. Nevertheless, informed operators and trained aircrew should be able to handle these day-to-day operational decisions safely. In this vein, it is understood that crew training under real-world decision-making situations increases the likelihood of safe operational decisions. Subsequent to a DC-8 runway excursion at Moncton, New Brunswick (A91A0198), the involved carrier undertook several corrective measures, including the use of simulator training to assist crews in the decision-making process during approaches in reduced visibilities (such as the conditions encountered in the occurrence). In its final report on the occurrence, the Board encouraged such preventive action taken by the aviation community independent of regulatory requirements. However, the Board also expressed concern that other operators and aircrew without benefit of similar training programs and guidelines on the handling of critical decisions might continue to place their aircraft in unsafe situations. Like the Convair 580 aircrew involved in the Tofino occurrence, most of the aircrew involved in the other incidents/accidents had not received formal crew resource management (CRM) or pilot decision-making (PDM) training. (The operators and aircrew involved in the occurrences listed in Appendix D may have subsequently taken action with respect to CRM and PDM training.) In its Commercial Pilot Survey (1991), Levels III to VI Air Carrier Operations, the TSB found that only 22 per cent of the respondents indicated that CRM training was provided by their employer and that decision-making training was available to only 27 per cent. Other countries have recognized the merits of this type of training; reportedly, the Federal Aviation Administration in the United States will require, by late 1995, resource management training for airlines to improve communication and co-ordination among crew members. In its Safety Study of VFR Flight into Adverse Weather (1990), the Board supported TC's initiative to evaluate pilot decision-making skills in the Private Pilot Licence flight test, and recommended that the Minister of Transport devise and implement a means of regularly evaluating the practical decision-making skills of commercially employed pilots in small air carrier operations (TSB A90-86). TC responded that Pilot Proficiency Checks would provide an assessment of a pilot's ability to make reasoned and timely decisions when faced with a simulated emergency situation. TC also indicated that it would keep abreast of developments in the field of decision-making training and assessment, and would not hesitate to introduce improvements. The eight referenced occurrences and the one at Tofino involved a total of 188 crew and passengers on board nine aircraft; eighteen fatalities resulted. The potential for more serious consequences was high. All of these occurrences were after the issuance of TSB recommendation A90-86 and for the most part involved small air carriers. The inappropriate decisions taken in these occurrences were not linked to emergency situations that would normally be tested on Pilot Proficiency Checks. Furthermore, the Board understands that there are still no requirements or established guidelines for ongoing training and evaluation of decision-making skills in the routine situations that commercial pilots face day-to-day. While the commercial aviation community has broadly embraced the concepts of CRM and PDM training, formal programs are only being administered on a voluntary, ad hoc basis. Consequently, ineffective resource management and faulty decision making continue to contribute to unsafe situations in commercial air transportation. Notwithstanding the many pressures in the commercial flying environment that come to bear on operators and aircrew, the Board believes that, with the correct tools and skills, the likelihood of inappropriate decisions can be reduced. While some large air carriers can develop the necessary training on their own, other operators will require direction and assistance in setting up meaningful training programs. Therefore, to ensure that all operators and aircrew involved in commercial aviation have access to training for better coping with day-to-day operating decisions, the Board recommends that: The Department of Transport establish guidelines for crew resource management (CRM) and decision-making training for all operators and aircrew involved in commercial aviation; and The Department of Transport establish procedures for evaluating crew resource management (CRM) and pilot decision-making (PDM) skills on a recurrent basis for all aircrew involved in commercial aviation.